Healthcare Provider Details

I. General information

NPI: 1497264618
Provider Name (Legal Business Name): AMANDA MARIE KUBILUS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE ETTINGER CRNP

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 JEFFERSON AVE STE 203
SCRANTON PA
18510-1638
US

IV. Provider business mailing address

610 WYOMING AVE
KINGSTON PA
18704-3702
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-9997
  • Fax: 570-344-3158
Mailing address:
  • Phone: 570-288-5441
  • Fax: 570-288-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP017826
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017826
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: